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Monday, 26 January 2015

Michael Porter’s book "Redefining Healthcare" provides the basis of the value chain of a clinical trial. He says: don’t worry so much about the clinical practice guidelines, focus, instead, in sharing with the patient the health goals that you reasonably expect to obtain, clarify either how much of the outcome depends on the patient or how much depends on the professionals involved. Then focus on measuring the achievements in order to know at what cost you achieved them and compete in the healthcare market with these values in hand.

The clinical process’ difficulties should not cause you to lose focus: the clinical effectiveness is the only objective.

According to the methodology Care Delivery Value Channel (CDVC), the creators of a clinical trial should be able to define how to address each of the stages of a clinical trial: prevention, diagnosis, preparation, response, recovery and follow-up or monitoring. At the same time it must be ensured that the patient flows through the process smoothly, without any surprises or poor coordination, but with assurances and being kept well informed.

Dr. Benito Fontecha is a geriatrician and Twitter user, he is not too active on the network, but he is very selective and the other day had the good idea of writing a tweet alerting us of the appearance of a very interesting post on the JAMA Internal Medicine blog. This article, linked to by Dr. Fontecha, is signed by two medical editors of a commendable section of the magazine called: Teachable moments.

Monday, 12 January 2015

Saurabh Jha, a radiologist at the Hospital of the University of Pennsylvania, in an article in New England (From imaging gatekeeper to service provider: a Transatlantic journey) explains that when he undertook MRI in the UK, residents feared the radiologists, not in vain, since one of them known as “Dr. No”. Migrated to the United States, quickly realized that there, the radiologists who were operating and issuing invoices as service providers, were rather “Dr. Yes”. The involvement of the radiologist in clinical reasoning was gone.

There is a widespread perception that the large investments of modern screening equipment are increasing their disproportionate use and the position of the radiologists, many of them involved in investments, is far from the function of gatekeepers, so praised by Dr. Jha. To this effect, it is revealing in a letter published in JAMA Internal Medicine (Overuse of Magnetic Resonance Imaging) about a consensus methodology (Rand Corporation University of California Los Angeles UCLA) to determine the degree of indication of MRI for low back pain and headache cases. The results say that 77% of the experts consulted, for example, believe that the MRI indication for back pain of less than 6 weeks duration is inappropriate or not well founded.

Monday, 5 January 2015

Hospital medical divisions are based on rigid organizational charts, in accordance with the official medical specialties. This organizational model is quite efficient when you need to provide services to patients with acute pathologies, especially when the derived procedures are more or less standardized. But in any other circumstances, of which there are plenty, the shortcomings found in coordination between medical services often cause frankly disappointing results that leave a lot of room to be improved.

In the fields of Mental Health and Oncology, particularly those sensitive to transversality, long ago instruments designed to overcome the closed compartments (circuit meetings, tumours committees) were created. These organizational models are based on protocols, individualized treatment plans and a lot of intense coordination; and, as a consequence of the positive results of these experiences, we have witnessed the emergence of the Integrated Practice Units, which are often initiatives that want to go beyond simple coordination, although most of them fail to overcome two tough limitations: real management autonomy (can they contract?) and lack of own resources (do they have an attached budget?).

Integrated Practice Units

At the moment, we're seeing many official initiatives aimed at giving legal backing to the establishment of Integratec Practice Units, precisely to overcome the above obstacles and thus get more management autonomy and accountability of clinicians in the management of resources. Even admitting that this new framework is encouraging, the question remains: Why do we want Integrated Practice Units? Will they bring more value or end up as a new constellation in the firmament of the chaotic management of patients with complex and little standardisable pathologies?